My long-term career goal is to be a national leader in cardiovascular quality and effectiveness research by systematically building a research portfolio on optimizing the use of noninvasive cardiovascular tests (NCT). This research and training proposal will enable my transition into an independent physician investigator. The goal of the research proposal is to optimize NCT quality by reducing underuse and overuse of NCT. Clinical practice guidelines define scenarios where use of NCT is rated ?must-do? (improves patient outcomes) or ?rarely appropriate? (provides no net benefit to patients). However, rates of must-do NCT are suboptimal and rates of rarely appropriate NCT remain high, leading to adverse patient outcomes. We propose to use the positive deviance approach to optimize NCT quality: by identification and in-depth study of hospitals that demonstrate exceptional quality (positive outliers), we will identify best practices that could lead to national improvements in NCT quality. We will 1) identify and characterize hospital outliers in use of four major ?must- do? and ?rarely appropriate? NCT using claims data, 2) interview key informants at positive outlier hospitals to understand and identify processes and structures of care that affect NCT quality, and 3) develop and pilot a hospital survey to determine the presence of these care processes. In a subsequent R01 we will survey hospitals nationally; link data on hospital NCT use to correlate care processes with NCT quality; and disseminate evidence-based ?best practices? to optimize NCT quality and improve patient outcomes. My training objectives proceed in a logical fashion with my research aims to prepare me for the transition to an independent research career in NCT quality. These include: 1) acquiring expertise in three common methods of healthcare quality assessment (multilevel regression modeling, qualitative methods, and survey methods); 2) conducting practical research identifying strategies to optimize use of NCT; and 3) developing the skills necessary for effective dissemination of research findings and securing independent research funding. I will accomplish these training objectives through formal coursework, guidance from my mentors, attendance at seminars, and hands-on research with publication of findings. This multi-modal approach will enable me to acquire new knowledge in areas critical to achieving my career goals, implement the proposed research plan, and build an independent research program with the ultimate goal of receiving R-level funding. The environment at the University of Colorado Denver (UCD) is uniquely equipped to support my training needs. My primary mentor is P. Michael Ho, MD, PhD, a nationally recognized leader in cardiovascular quality and outcomes research with a proven track record of mentorship and securing grant support. My multidisciplinary mentoring team includes both methodologic and content experts that are highly relevant to my research and training goals. The practical resources of the School of Medicine and the Outcomes Research Center at UCD provide an extensive infrastructure for data management and biostatistical support.